DISCHARGE SLIP

CLIENT NO. _____________

PATIENTS SURNAME: _____________ GIVEN NAME:________________ MIDDLE NAME_____________

MOTHER’S MAIDEN NAME:___________________ FIRST NAME_______________M.I______________
FATHER’S SURNAME: ___________________ FIRST NAME:___________________M.I:______________
DATE OF BIRTH :_______________________ TIME OF BIRTH: _________ SEX:________
NEWBORN SCREENING:__________________ HEARING TEST:_____________________

DISCHARGE DIAGNOSIS
TYPE OF BIRTH: G__P__ (____)
PRESENTATION: IE:
WEIGHT: CONDITION:
LENGTH: MEDICINES:
HEAD CIRCUMFERENCE: DIET:
CHEST CIRCUMFERENCE:
ABDOMINAL CIRCUMFERENCE:
FEEDING OBSERVED:
VIT K GIVEN:
BCG GIVEN:
HEPA B GIVEN:
OPTHALMIC OINTMENT:

TAGUBILIN/INSTRUCTION

 PANATILIHING MALINIS AT TUYO ANG PUSOD(KEEP CORD CLEAN, EXPOSED AND DRY)
 WALANG DAPAT ILAGAY SA PUSOD (PLACED NOTHING ON THE CORD)
 HINDI KAILANGFAN NG BIGKIS (NO BINDERS)

KOMUNSULTA SA DOKTOR KAPAG: (CONSULT A DOCTOR IF:)

 MAY PULA O NANA SA PUSOD (CORD REDNESS OR DISCHARGE)
 LAGNAT O KUMBULSYON (FEVER OR CONVULSION
 PAGSUSUSKA (VOMITTING)
 AYAW DUMEDE, MATAMLAY(POOR SUCK, POOR ACTIVITY)

ANG GATAS NG INA ANG PINAKAMASUSTANSYA AT PINAKA MAHUSAY NA GATAS(NO WATER, NO FOOD
EXCEPT BREASTMILK)

GATAS NG INA ANG IPASUSO KAY BABY SA LOOB NG ANIM (6) NA BUWAN PADEDEHIN TUWING IKA 2-3
ORAS O TUWING IYAK.(BREASTFEE EVERY 2-3 HOURS /PER DEMAND, BREASTFEEDING FROM BIRTH TO SIX
MONTHS AND UP TO 2 YEARS AND BEYOND.)

PAINITAN SA ARAW ANG BOUNG KATAWAN NI BABY NG 15-20 MINUTO ARAW-ARAW SA UMAGA (15-20
MINS. DAILY SUNLIGHT EXPOSURE OF BABY’S WHOLE BODY)

FOLLOW UP SCHEDULED
DATE:_____________
TIME:_____________